Relationship of the Dental Aesthetic Index to the oral health-related quality of life

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1 Originl Article Reltionship of the Dentl Aesthetic Index to the orl helth-relted qulity of life Asm Ashri ; Alize M. Mohmed b ABSTRACT Objective: To ssess the impct of mlocclusion on the qulity of life. Mterils nd Methods: This cross-sectionl study involved 150 subjects ttending the Primry Cre Unit with no history of orthodontic tretment. The Dentl Aesthetic Index (DAI) with 10 occlusl chrcteristics were mesured on study models. Orl helth-relted qulity of life (OHRQoL) ws ssessed with the Mlysin version of the Orl Helth Impct Profile questionnire (OHIP-14). The Spermn rnk-order correltion coefficient ws used to evlute the reltionship between the mlocclusion nd qulity of life. Results: Significntly wek correltions (r 5.176) were found between the DAI nd the OHRQoL. Femles nd the younger ge group (12 19 yers) tended to score higher on the OHIP-14 thn their counterprts. For mles, domin 3 (psychologicl discomfort; r 5.462), domin 4 (physicl disbility; r 5.312), domin 7 (hndicp; r 5.309), nd overll score (r 5.289) were wek correltes but significnt to the DAI compred with femles. The older ge group showed significnt wek correltion in domin 3 (psychologicl discomfort; r 5.268) nd domin 7 (hndicp; r 5.238), wheres the younger ge group showed no correltion with ny domin. Conclusions: The DAI score does not predict the effect of mlocclusion on the OHRQoL. (Angle Orthod. 2016;86: ) KEY WORDS: Dentl Aesthetic Index; Orthodontic tretment need; Qulity of life INTRODUCTION There re mny objective indexes to mesure orl helth. These indexes cn determine how much person s orl helth devites from the idel or norml condition; therefore, pproprite tretment cn be provided. In mlocclusion, physicl devition from the idel occlusion, there is high degree of subjectivity with vriety of perceptions of orthodontic tretment need mong the popultion. 1 Trining Lecturer nd Dentl Officer, Deprtment of Orthodontics, Fculty of Dentistry, Universiti Kebngsn Mlysi, Kul Lumpur, Mlysi. b Hed, Orthodontics Specilist nd Lecturer, Deprtment of Orthodontics, Fculty of Dentistry, Universiti Kebngsn Mlysi, Kul Lumpur, Mlysi. Corresponding uthor: Dr Alize Mrny Mohmed, Deprtment of Orthodontics, Fculty of Dentistry, Universiti Kebngsn Mlysi, Jln Rj Mud Abd Aziz, Kul Lumpur, Mlysi (e-mil: lizemrny@gmil.com) Accepted: April Submitted: December Published Online: My 27, 2015 G 2016 by The EH Angle Eduction nd Reserch Foundtion, Inc. The Index of Orthodontic Tretment Need (IOTN) is becoming the most commonly used index in orthodontic prctice. Menwhile, the Dentl Aesthetic Index (DAI) n lterntive form of index combines the clinicl nd esthetic spects of occlusion tht indirectly ssess the reltive socil cceptbility of dentl ppernce. 2 The DAI hs been proven to be relible, simple, vlid, nd user-friendly. 3,4 Furthermore, it cn be used nd dpted globlly nd crossculturlly without ny modifiction. 5 7 Unlike the IOTN, the DAI elimintes the need of seprte instrument to ssess the esthetic component. Silvol et l. 8 discussed the impct of orl helth on person s well-being from the functionl, socil, nd psychologicl spects. Although the DAI indictes the reltive socil cceptbility nd functionlity of dentl ppernce, 2 idelly the ptient s own psychosocil view should be included. 9,10 The ptient s psychosocil view would llow ech tretment pln to be tilored for the individul ptient, mximizing the tretment benefit. Ech ptient s self-wreness of his or her occlusion my be inconsistent with its severity. 9,11 Some ptients with severe mlocclusion re indifferent to their condition, while others re very concerned with only minor irregulrities. 9 This is how the use of n DOI: /

2 338 ASHARI, MOHAMED occlusl index lone might be problem: when ptient without psychosocil need for tretment is deemed to be in need of tretment. As orthodontists hve become more wre of ptients qulity of life in orl helth, more orl helth-relted qulity of life (OHRQoL) questionnires hve been developed over the pst two decdes to ssess ptients perspectives nd needs towrd their mlocclusion. 12 One of the emerging tools is the Mlysin cross-culturl dpttion, the Orl Helth Impct Profile (OHIP-14), 13 which hs been verified to be vlid nd relible, nd it hs been used in ntionl survey. 14,15 The introduction of the OHIP-14 highlights the importnce of not only improving the mlocclusion, but lso the ptient s psychosocil well-being. A generic questionnire hs the benefit of cpturing unforeseen effects tht might go unnoticed by specific instrument. 16 The DAI is n pprisl mde by the dentist, while the OHRQoL is n evlution by the ptients themselves. Therefore, it is importnt to ssess whether ny correltion exists between these two instruments. Mny studies hve been done to ssess the correltion of mlocclusion with the OHRQoL. 12 However, there is still mbiguity in their reltionship. Nevertheless, systemtic review conducted by Zhijin et l. 17 covering publictions from 1960 to 2007 found only 23 rticles tht met the inclusion criteri. The uthors concluded tht there is moderte ssocition between mlocclusion nd the QoL. In the fce of this inconsistency, the purpose of this study ws to investigte the reltionship between the DAI nd the ORHQoL nd to ssess the impct of mlocclusion on the OHRQoL in the dolescent nd dult popultion. MATERIALS AND METHODS This study ws undertken fter obtining detiled protocol nd ethicl pprovl from the Reserch Ethics Committee of Universiti Kebngsn Mlysi (UKM /244/2). Smple size clcultion ws performed using the Rosoft online smple-size clcultor (Rosoft Inc, Settle, Wsh). With mrgin of error of 5% nd confidence level of 95%, the trget smple size ws determined to be 150 (including 10% dropout). A systemtic convenience smpling ws done. A totl of 159 subjects from the Primry Cre Clinic of UKM were invited to prticipte in this study. Consent ws obtined from ech subject fter we explined the nture nd purpose of the study. For subjects under 18, consent ws obtined from their gurdins. The inclusion criteri were (1) ge between 12 to 35 yers, (2) ll teeth present excluding 3rd molrs, (3) no history of orthodontic tretment, (4) no history of untreted dentl cries, (5) no history of poor periodontl helth or previous extrction, (6) no chronic medicl conditions or crniofcil nomlies, nd (7) Mly literte. A simple clinicl exmintion ws performed by A.A., followed by impressions of the mxillry nd mndibulr rches, which were tken with fst-setting lginte nd conducted under strict infection control procedures. The impressions were sent directly to the lbortory nd study models were prepred. Subjects were then given self-dministrted questionnire to gther sociodemogrphic nd OHR- QoL informtion. The short version of the OHIP-14 ws used to reduce time nd burden on the ptients, s long questionnires could led to inccurte results. 18 OHIP-14 focuses on the impct of OHRQoL vi seven conceptul domins (two items per domin). A 5-point Likert scle ws used to rte the frequency of occurrence of prticulr problem cptured by the domin. The responses rnge from lwys to never (1 to 5) with n dditionl X- I don t know. The two methods of scoring were (1) Additive (ADD) scores, rnging from 0 to 56, were clculted by dding up the response codes for ech item, nd (2) domin scores were clculted by verging the score for ech domin. High scores indicted poor OHRQoL. The kpp vlue in rerting the questionnire by 15 (10%) of the subjects ws determined to be 0.86 t n intervl of 2 weeks during their reppointment schedule for the dentl tretment. This showed good intrexminer relibility. The DAI score ws obtined using the stndrd DAI regression eqution index ccording to WHO guidelines. 19 DAI consists of 10 occlusl chrcteristics relted to dentofcil nomlies ccording to the three components of the dentition: spcing, crowding nd occlusion. In order to obtin ccurcy with the use of the DAI index, the exminer underwent trining nd clibrtion exercise, mesuring the prmeters for the DAI components directly from the study model with digitl cliper. Triplicte mesurements were mde nd the men ws obtined. After ptient s totl score hd been clculted, it ws grded on scle of the most nd lest socilly cceptble dentl ppernce tht would plce it in the tretment-mndtory ctegory (Tble 1). Intrclss correltion showed good intrexminer relibility (.82). Nine broken study models were eliminted, leving only 150 to be included in the nlysis. The dt nd reltionship between the DAI nd OHRQoL were nlyzed using the Sttisticl Pckge for Socil Science softwre for Windows version 22.0 (SPSS Inc, Chicgo, Ill).

3 DAI AND OHRQOL 339 Tble 1. Distribution of Sociodemogrphic Chrcteristics, DAI, nd OHIP-14 Scores Ctegory n % Gender Mle Femle Eductionl bckground Primry school Secondry school University Others Ethnic group Mly 115 (76.7) Chinese 16 (10.7) Indin 12 (8.0) Others 7 (4.6) DAI scores Grde 1 (,25) No/slight tretment need 30 (20.0) Grde 2 (26 30) Tretment elective 40 (26.7) Grde 3 (31 35) Tretment highly desirble 37 (24.7) Grde 4 (.35) Tretment mndtory 43 (28.7) Age group (49.3) (50.7) DAI indictes Dentl Aesthetic Index. RESULTS A totl of 159 subjects mong the dolescent nd dults prticipted in the study. However, nine records were excluded from nlysis due to the broken study models. As shown in Tble 1, of the 150 subjects, pproximtely two-thirds were femle (102; 68%). Most of the subjects hd t lest university-level eduction (67; 44.7%), nd 64 (42.7%) were educted only to the secondry level (132; 40.8%). Tble 2 depicts the men, stndrd devition, medin, nd rnge observed in OHIP-14 for ech domin in ll 150 subjects. The overll men score (6 SD) for OHIP-14 ws Domin 3 (psychologicl discomfort) hd the highest impct, with men score of The domin with the lest impct ws domin 6 (socil disbility), with Tble 2. Men, Stndrd Devition (SD), Medin, nd Rnge Observed in OHIP-14 OHIP-14 Domins Men (SD) Medin Rnge Observed D1. Functionl limittion 2.26 (1.6) D2. Physicl pin 2.12 (1.4) D3. Psychologicl discomfort 3.71 (2.0) D4. Physicl disbility 1.91 (1.8) D5. Psychologicl disbility 1.51 (1.5) D6. Socil disbility 0.6 (1.2) D7. Hndicp 1.6 (1.6) OHIP-14 totl (8.12) OHIP-14 indictes Orl Helth Impct Profile; D, domin. men score of Femles scored higher mens in four out of seven domins (domin 4, psychologicl discomfort; domin 4, physicl disbility; domin 5, psychologicl disbility; domin 6, socil disbility; domin 7, hndicp) long with the totl score. Generlly, the younger ge group (12 19 yers) scored higher mens thn did the older ge group (20 35) in five out of seven (domin 3, psychologicl discomfort; domin 4, physicl disbility; domin 5, psychologicl disbility; domin 6, socil disbility; domin 7 hndicp) s well s the totl score. Tble 3 shows the Spermn rnk-order correltion coefficients between the DAI nd OHIP-14 scores, which showed significnt but lmost no correltion (r 5.176) between the two instruments t ll grdes of the DAI summtive score. Domin 3 (r 5.223; P,.01) nd domin 4 (r 5.220; P,.01) hd the strongest correltion. Domin 7 (r 5.198; P,.05) ws observed to hve significnt but weker correltion. Tble 4 displys the Spermn rnk-order correltion coefficients between the DAI score nd the OHIP-14 score for gender nd ge ctegories. Although femles on verge hd slightly higher impct scores thn mles, none of the correltions between the DAI nd OHIP-14 ws significnt except for domin 4 (r 5.196). However, for mles there were significnt correltions in domins 3 (r 5.462), 4 (r 5.312), nd 7 (r 5.309), nd totl score (r 5.289). Between the ge groups, no significnt correltion ws observed in the ge groups, wheres the older ge groups showed significnt but wek correltions in domin 3 (r 5.268) nd domin 7 (r 5.248). There ws no correltion in the totl score for either ge group. DISCUSSION Mny studies hve ssessed the influence of mlocclusion on the qulity of life. 9,12,16,17,20 24 A study in Mlysi utilized IOTN s the instrument. 20 Most of these studies hve focused on specific group such s children, orthodontic ptients, or ptients seeking orthodontic cre. 9,12,16,17,20 24 The current study used DAI s the instrument nd covered wider ge rnge of popultion tht comes for primry dentl cre, not specificlly seeking orthodontic tretment. Studies on orthodontic ptients hve focused on physicl pin, psychologicl discomfort, nd disbility. 12,20,25 In this study, the ptients in primry cre lso indicted tht psychologicl discomfort (domin 3) hd the highest orl impct mong the seven domins (Tble 2). Feu et l. 9 reported tht psychologicl discomfort ws the secondmost negtively impcting domin. One study hs shown tht esthetic improvement in mlocclusion provides improvement in orl helth relted qulity of life, prticulrly in psychologicl

4 340 ASHARI, MOHAMED Tble 3. Spermn Correltion Between DAI nd OHIP-14 D1. Functionl Limittion D2. Physicl Pin D3. Psychologicl Discomfort D4. Physicl D5. Psychologicl D6. Socil D7. Hndicp Sum OHIP-14 r **.220** *.176* P DAI indictes Dentl Aesthetic Index; OHIP-14, Orl Helth Impct Profile; D, domin. Spermn s rnk correltion nlysis: *P,.05; **P,.01. discomfort nd psychologicl disbility. 8 It is resonble to ssume tht spects of physicl ppernce ply n importnt role in mlocclusion, since it is more of n esthetic devition from the idel of norml occlusion. 26 The DAI ws designed to ssess reltive socil cceptbility of dentl ppernce, nd this ws reflected in the results of this study, in which the DAI scores were significntly correlted with the three domins tht include physicl ppernce. Four domins (3, 4, 6, nd 7) of OHIP-14 cover spects of fcil ppernce. However, only three domins (3, 4, nd 7) were most ffected. Domin 3 (psychologicl discomfort), which ws found to be relted to esthetic impirment, 27 ws observed to hve the highest impct in the study. Liu et l. 12 reported correltions of mlocclusion with the OHIP- 14, nmely, tht domins 3, 5, 6, nd 7 were significntly ffected. In nother study, discomfort in eting (n spect of physicl discomfort) ws lso significntly correlted with mlocclusion. 22 In the gender ctegory, femles generlly scored higher on their OHIP-14 thn did mles. This trend ws lso reflected in other studies. 9,20,21,25 Femles re thought to be more self-conscious, nd they tend to report higher orl impct thn do mles. 25 This higher score my be due the lrger number of femles (twice s mny) compred with the mles (Tble 1). However, mles lso tend to score lower thn femles in three domins (psychologicl discomfort, physicl disbility, nd hndicp) nd in totl OHIP-14 scores wherein significnt correltions existed (Tble 4). This indictes tht lthough mles tend to be less conscious of their ppernce, 28 they probbly re more wre of their mlocclusion. For the ge ctegory, the younger group scored higher in OHIP-14 but there ws no correltion with the DAI. The older group scored lower but hd significnt (P,.05) correltions in two domins (psychologicl discomfort nd hndicp; Tble 4). The tendency for the younger group to overrte their problems is probbly due to the fct tht this ge group represents period of intense socil nd ffective reltionships, in which dentl esthetics nd smile hve strong potentil to influence the individuls physicl ttrctiveness. 26 Older groups tended to be more correlted with their mlocclusion, even though they scored lower. This is in greement with Abu Alhij et l., 29 wherein the correltion between mlocclusion nd OHRQoL ws higher in the older groups. In this study, OHIP-14 exhibited few domins (minly 3, 4, nd 7) tht hve significnt but wek correltions with ptients mlocclusion, which suggests tht the higher the grde of mlocclusion, the more likely re these domins ffected. This ws lso observed in nother study, wherein qulity of life ws relted to emotionl rther thn functionl or socil well-being. 23 The generic questionnire does not directly ssess mlocclusion, 12 which is n symptomtic devition from Tble 4. Ctegories Spermn Correltion Between DAI nd OHIP-14 According to Gender nd Age Groups D1. Functionl Limittion D2. Physicl Pin D3. Psychologicl Discomfort D4. Physicl D5. Psychologicl D6. Socil D7. Hndicp Sum OHQoL Gender Mle r **.312* *.289* P Femle r * P Age groups r P r * *.207 P DAI indictes Dentl Aesthetic Index; OHIP-14, Orl Helth Impct Profile; D, domin. Spermn s rnk correltion nlysis: * P,.05; ** P,.01.

5 DAI AND OHRQOL 341 the esthetic norm rther thn n cute disese. 12,30 Therefore, the sensitivity of OHIP-14 to chnges in mlocclusion is lower compred with other orl conditions. Currently, no vlidted QoL instrument cn be specificlly pplied to mlocclusion. Further reserch is required to integrte condition-specific questionnire for mlocclusion, which should hve higher sensitivity to ssess the impct of mlocclusion on the ORQoL. We lso noted tht this wek correltion is universl finding in other studies s well. It my suggest tht the correltion vlues of.20 to.30 re the strongest correltion vlues between the DAI nd OHRQoL. The limittions of this study must be tken into considertion. The subjects in this study were selected by convenience smpling: ptients who sought tretment t the primry dentl clinic. Block smpling ws not dministered, hence the lrge numbers of femles. In ddition, those who do not seek dentl tretment might hve different priorities nd different perspectives in their OHRQoL. 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